itchy, scratchy, red and patchy: derm tips for primary care · desloratadine*, ebastine,...
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Itchy, Scratchy, Red and Patchy: Derm tips
for primary care Robert Gniadecki, MD
Faculty/Presenter Disclosure
• Faculty: Robert Gniadecki
• Relationships with financial sponsors:
• Grants/Research Support: N/A
• Speakers Bureau/Honoraria: Therakos; Mallincrodt; Janssen; Abbvie; Novartis; Leo Pharma
• Consulting Fees: N/A
• Patents: N/A
• Other: Mallincrodt; Janssen; Amgen; Abbvie; Eli Lilly; Sanofi; Novartis; Leo Pharma
Disclosure of Financial Support
• This program does not receive financial support.
• This program is presented by the ACFP without financial support.
• The ACFP provides a speaker fee and expense support for presenting at the event.
• This program does not receive in-kind support.
• This program is presented by the ACFP without in-kind support.
Mitigating Potential Bias
• Material/Learning Objectives and/or session descriptions were developed and reviewed by the Planning Committee composed of experts/family physicians/allied care professionals responsible for overseeing the program’s needs assessment and subsequent content development to ensure accuracy and fair balance.
• Consideration was given by the Planning Committee to identify when speakers’ personal or professional interests may compete with or have actual, potential, or apparent influence over their presentations.
• Information and/or recommendations in the program are evidence- and/or guidelines-based, and the opinions of the independent speakers will be identified as such.
urticaria • Smooth, slightly elevated papules or plaques (wheals) that are
erythematous and that are often attended by severe pruritus. • Individual lesions resolve without scarring in several hours. • Most cases of urticaria are self-limited and of short duration
(acute urticaria). Chronic urticaria is > 6 weeks • Most cases are NOT allergic • Causes:
A. foods B. medications (especially aspirin, NSAIDs, antibiotics, over-the-
counter (OTC) medications, herbs, and supplements) C. infections D. physical stimuli (eg, heat, cold, pressure, vibration) E. insect bites or stings
Urtica dioica
International EAACI/GA2LEN/EDF/WAO guidelines: definition and classification of
chronic urticaria
Zuberbier T, et al. Allergy 2018;73:1393–1414; Zuberbier T, et al. Allergy 2009:64:1417–26..
Urticaria may coexist with angioedema
Angioedema:
Swelling of the subcutaneous tissue
Painful rather than itchy
Common areas involved: face, lips, eyelids, genitals, hands and feet
Usually resolves in less than 72 hours
Zuberbier T, et al. Allergy 2018;73:1393–1414
Work-up
Differential blood count
ESR or CRP
Omission of suspected drugs (e.g. ACE-I, NSAIDs)
Directed investigations Causes Description Tests
Infectiousdiseases
Bacterial,viral,parasitic,orfungalinfectionshavebeenimplicatedtobeunderlyingcausesofCIUFrequency/relevancevariesbetweenpatientgroupsandregions
H.pylori,Streptococci,Staphylococci,Yersinia,Giardialamblia,Mycoplasmapneumonia,Hepatitisvirus,Norwalk,ParvovirusB19,Herpessimplex,Entamoebassp.,Blastocystisspp.
TypeIallergy Rarebutcanbeconsideredinpatientswithintermittentsymptoms
Skintests,includingphysicaltests(eg,coldprovocation)
Pseudo-allergy Pseudo-allergen-freediet AvoidanceofNSAIDsfor3weekstoruleoutnon-allergichypersensitivityreaction
Functionalautoantibodies
AutoantibodiesagainstIgEorFcε�R1 Autologousserumskintest
Thyroidcauses Thyroidhormonesandautoantibodies
Malignancy Notrecommendedroutinely,butwarrantedifsuggestedbypatienthistory
directed(PET-CT,markers,other)
Severesystemicdisease
Tryptase
Zuberbier T, et al. Allergy 2018;73:1393–1414
CSU - treatment algorithm 1. Second generation antihistamines (2 weeks) (bilastine* cetirizine*,
desloratadine*, ebastine, fexofenadine*, levocetirizine* and rupatadine*)
2. Increase dose x2 and then x4 (max 4 weeks)
3. Add Omalizumab
4. finally, as fourth line, consider ciclosporin. For exacerbations consider Prednisone
*-can be safely used in children
Loratadine can safely be used in pregnant women based on the metaanalysis data and EAACI recommendation (not in label) (Schwarz, Drug Safety 2008;31:775-788)
Zuberbier T, et al. Allergy 2018;73:1393–1414
H1-antihistamine Standarddailydose
Cetirizine (Reactine®) 10 mg
Fexofenadine (Allegra®) 60 mg bid
Loratadine (Claritin®) 10 mg
Desloratadine (Aerius®, Clarinex®) 10 mg bid
Levocetirizine (Xyzal®) 10 mg bid
Rupatadine 10 mg
Bilastine 20 mg
Are 1st generation antihistamines of any value?
Zuberbier T, et al. Allergy 2018;73:1393–1414
NO drowsiness, bad quality sleep, anticholinergic effects, QT interval prolongation, …..
Urticaria - derm tips ● It is a clinical diagnosis ● If >6 weeks - chronic urticaria. ○ Look for drugs (NSAID) as triggers ○ Ask for possible inducible urticaria (cold, heat, pressure,
scratching, cholinergic (sweating), sunlight) and try to provoke
○ All remaining cases will likely be chronic idiopathic urticaria
○ Don´t do extended workup ● Treat with 2nd generation antihistamines, if failure increase
the dose x2 and x4 ● Refer resistant cases to dermatology
https://jamanetwork.com/journals/jama/fullarticle/1829686
Itchy
Pink
Slightly scaly
How to recognize AD?
How to diagnose?
age, location, scaly-itchy-red rash
What is prognosis?
80% spontaneous remission
5% persists to adulthood
food - environment - climate affect AD
What are the complications?
hand eczema and allergic eczema
20% asthma
infections: impetigo, herpes, molluscum
★ Exacerbation: mild corticosteroids (1% - 2 % Hydrocortisone) for 7-14 days with slow tapering
Treatment of pediatric patients: Mild AD
Eichenfield LF, et al. Pediatrics 2015;136:554-565
★ Moisturizers (creams, fragrance- and parabene free)
★ Bath (short)
★ Dilute bleach bath 0.5 cups sodium hypochlorite per 40 gallons bathtub
★ Trigger avoidance (soaps, wool, cold weather)
How many grams of cream should be prescribed weekly for sufficient therapy
(whole body, used twice daily) ? - infant? - child? - adult?
100 - 200 - 300 g
Eichenfield LF, et al. Pediatrics 2015;136:554-565
Exacerbation: medium potency corticosteroids (e.g. 0.1% mometasone fuorate) for 7-14 days with slow tapering
Exacerbation: medium potency corticosteroids (e.g. 0.1% mometasone fuorate) for 7-14 days with slow tapering
Treatment of pediatric patients: Moderate AD
aAs tolerated during flare; direct use of moisturizers on inflamed skin may be poorly tolerated; however, bland petrolatum is often tolerated when skin is inflamed. . Eichenfield LF, et al. Pediatrics 2015;136:554-565.
★ Moisturizers (creams, fragrance- and parabene free)
★ Bath (short)
★ Dilute bleach bath 0.5 cups sodium hypochlorite per 40 gallons bathtub
★ Trigger avoidance (soaps, wool, cold weather)
★ Maintenance: non-steroid calcineurin inhibitor (tacrolimus or pimecrolimus) / mild corticosteroid
Exacerbation: medium potency corticosteroids (e.g. 0.1% mometasone fuorate) for 7-14 days with slow tapering
Atopic dermatitis - tips
● It is a clinical diagnosis - age and lesion distribution ● Moisturize, moisturize, moisturize ● Infection control ● Calcineurin inhibitor as maintenance ● Intermittent steroids for exacerbations ● Think of risk of occupational hand eczema in adolescents ● Insufficient control - refer
SKINDISEASE
JOINTDISEASE
CO-MORBI-DITIES
Psycho-logical
Hepatic
Cardio-vascular
Diabetesand
metabo-lism
Depres-sion
Cancer
Renalinsuf-ficiencyNail
disease
Spondylo-arthro-pathy
Peripheral
arthropathy
Softtissueinflammation
IBD
MS
Psoriasis reduces life expectancy by 5 years
GulliverW,etal.BrJDermatol2008;159(Suppl2):2–9.
44% of deaths in psoriasis are related to cardiovascular disease vs 36% in the normal
population
Practice gap: Suboptimal medical management of coronary risk factors in patients with psoriasis
AhlehoffO,SkovL,GislasonG,LindhardsenJ,etal.(2012)PharmacologicalUndertreatmentofCoronaryRiskFactorsinPatientswithPsoriasis:ObservationalStudyoftheDanishNationwideRegistries.PLoSONE7(4):e36342.
Psoriasis - derm tips
● Screen your patients for CVD ● Severe psoriasis has the same weigh as diabetes when
calculating CVD risk
Efficacy of sunscreen in real world
Sunscreens - derm tips
● Sunscreen DO protect against skin cancer and skin aging ● Sunscreens DO NOT have appreciable hormonal side
effects ● SPF30 is sufficient , but must be applied 2mg/cm2 ● One application daily is enough
Strategy 1: Apply before sun exposure and reapply once within1 h.
People apply usually a mean quantity of sunscreen of 0.71 mg/cm2 at first application and 1.27 mg/cm2 at second application
Strategy 2: Use higher SPF than necessary.
There is a linear relationship between application density and the actual SPF
Sunscreens labeled SPF 70 and 100 applied at 0.5 mg/cm2 provided an actual SPF value of, respectively, 19 and 27.